Massive Upper Gastrointestinal Bleeding

Audience This case is targeted to emergency medicine residents of all levels. Introduction Upper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah’s Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3 Educational Objectives By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. Educational Methods This simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Research Methods Following the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. Results Overall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. Discussion This case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah’s Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient’s clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade. Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. Topics Upper gastrointestinal bleed, hemorrhagic shock, Jehovah’s Witness, difficult airway.

If the instructor is unfamiliar with the suction-assisted laryngoscopy and airway decontamination (SALAD) technique for intubation in the setting of massive hematemesis, we recommend reading this and watching the video: • DuCanto J. SALAD. Open Airway. https://openairway.org/salad/. Published June 16, 2019. 7 To review pharmacologic options for the management of bleeding in a patient who refuses blood transfusion due to religious objection, we recommend the following sources: • Crookston K, Silvergleid A, Tirnauer J. The approach to the patient who declines blood transfusion. UpToDate. https://www.uptodate.com/contents/the-approachto-the-patient-who-declines-blood-transfusion.

Results and tips for successful implementation:
This simulation was designed for EM residents to improve their resuscitation skills by managing an extremely challenging case of massive UGIB that requires intubation and gastric balloon tamponade, in a patient who has a religious objection to blood product administration. The case was performed in a highfidelity simulation setting using an additional medium-fidelity modified intubating mannequin to simulate airway decontamination and a low-fidelity model of a stomach and gastroesophageal junction to allow placement and visualization of a gastric balloon tamponade device. To create realistic experience of an obscured airway and to practice the suction assisted laryngoscopy and airway decontamination (SALAD) technique, 7 we created a mediumfidelity contaminated airway model (Video 1). The model consisted of a standard intubating mannequin with the lungs and stomach removed. Through the inferior gastroesophageal opening, a 7.5 endotracheal tube was inserted with the balloon inflated to create a seal, and the back end was connected via a christmas tree connector and pediatric ECMO tubing to a bag of watered-down washable red paint to simulate blood. Endotracheal tubes were also inserted with inflated balloons into the bilateral lung openings, also from an inferior approach, to prevent simulated blood from draining out of the oropharynx through the lungs. This allowed rapid filling of the oropharynx with contaminant that required aggressive suction to allow airway visualization.
In addition, we purchased an expired Blakemore tube from dotmed.com for $120. Either a Minnesota tube or a Blakemore tube can be used for tamponade. The difference between the two can be discussed during the debriefing session. We used a clear plastic water bottle as a low-fidelity model of a stomach, with the mouth of the water bottle representing the gastroesophageal junction, to demonstrate appropriate balloon placement (Image 1).
Some of the additional tips for successful implementation of this include: • Create teams of 2-3 learners with mixed levels of training to balance experience levels with management of UGIBs and these complex procedures. Before the beginning of the case, allowing the team members to assign roles will help in running the case smoothly. • The nursing cues can be given for more junior learners to help them through the case. • The portion of the case with the Jehovah's Witness component can be entirely removed for junior learners.
The case was designed and implemented during the 2020-2021 academic year, during the COVID-19 pandemic. It was piloted in a socially distanced manner in 3 separate sessions, each involving 2 residents participating live in the simulation center and 10 residents observing and participating in the debrief via video conference. All learners were from the same residency program and were partnered to balance their level of training.
Following the simulation and debrief session, participants, including those who participated in-person and via video conference (n=37), were provided a survey to assess the educational quality of the simulation and were also asked for open-ended feedback. There were 16 respondents (43% of participating residents), including 5/6 (83%) live participants, 8 (50%) interns, 6 (37.5%) PGY-2s, and 2 (12.5%) PGY-3s. Overall, residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge as well as their procedural skills with regard to difficult intubations and placement of a Blakemore tube (Table 1).
The most common suggestions for improvement surrounded hands-on experience with the Blakemore tube. One resident suggested having both a Minnesota and a Blakemore tube available in-person for comparison. While this would certainly improve understanding of the differences, these devices are expensive and difficult to obtain for teaching purposes. An alternative would be to purchase the same balloon type that is available clinically to your residents. Another suggestion was to save additional time for residents, to practice placing the Blakemore tube after the debrief so they could practice the techniques that were just taught. Given the complexity of the case and of Blakemore tube placement, it may be beneficial to use this opportunity to use spaced repetition and set up a Blakemore tube placement procedure lab the following week.

Feedback
Year "Only thing I would add is let the residents try and set up and place the Blakemore tube after the debriefing session…Overall, one of my favorite sim cases." PGY-2 "I really appreciated the flow of the case. I thought the complexity was excellent and I felt challenged during the case." PGY-1 "Excellent case. Lots of things I didn't know that I didn't know." PGY-2 "The case very clearly exposed a gap in our knowledge on how to perform this high risk, low frequency procedure. I now have a much better understanding on how to [insert a Blakemore tube] thanks to the simulation." PGY-2 "About as hard as you can make a GIB case:" PGY-2 "Being able to see the Minnesota tube at the same time as the Blakemore would be helpful so we could really compare and contrast." PGY-1  A 46-year-old female with alcoholic cirrhosis presents with UGIB. Her vitals are initially borderline hypotensive, but she is ill-appearing and had a syncopal event this morning. While in the emergency department, she has an episode of massive bright red hematemesis and develops hemorrhagic shock. As the case progresses, the patient's husband informs the providers that she is a Jehovah's Witness. The patient will become more altered and continue to bleed requiring intubation and placement of balloon tamponade. The patient will need to be admitted to the intensive care unit (ICU) with the diagnosis of upper gastrointestinal bleeding secondary to esophageal varices.

Equipment or Props Needed:
Moulage for bruise on patient's forehead, spider angioma on abdomen, and scleral icterus Basin with red "blood" High-fidelity mannequin with monitor Medium-fidelity contaminated airway model using a modified intubating mannequin Low-fidelity model of gastroesophageal junction using a clear plastic water bottle Multiple suction catheters, including at least one large-bore catheter ( Background and brief information: A 46-year-old female brought in by her husband to the ED at a tertiary care center for "passing out" and "vomiting blood."

Initial presentation:
The patient is brought from home by her husband via private vehicle for hematemesis and syncope. The patient is ill-appearing but is able to answer questions. She is borderline hypotensive, tachycardic and tachypneic.
How the scene unfolds: A 46-year-old female is brought in from home by her husband for hematemesis and syncope. She had 2 episodes of 2 tablespoons of bright red hematemesis this morning and then became lightheaded and had a syncopal event just prior to arrival, prompting her visit to the ED. Learners should recognize stigmata of possible liver disease (lower extremity edema, scleral icterus) and should be concerned about potential for rapid decompensation. She should immediately be placed on the monitor, given 2 large-bore IVs, and started on octreotide, ceftriaxone, and a proton pump inhibitor for suspected UGIB. The dosing of the medications can be given by the learners or they may defer to pharmacy. Additional history should reveal a history of alcohol abuse, liver disease, and no blood thinners. If collateral history is obtained from the husband, he should not inform them of their religious objection to blood products unless asked specifically. He will offer this information voluntarily as soon as blood products are ordered.
Laboratory studies (point of care glucose, CBC, CMP, PT/INR, PTT, Beta-hCG, type and screen) should be ordered. A CT head without contrast should also be ordered to evaluate for subdural hematoma in the setting of head trauma (forehead bruising) in a patient who is a chronic alcoholic, but the patient will not be stable enough to go to radiology until after intubation and gastroesophageal balloon tamponade.
Regardless of initial actions taken by learners, the patient will develop massive hematemesis in the ED and become more altered, suggesting decompensation into hemorrhagic shock. Learners should call for uncrossmatched (O negative) blood and prepare for intubation. Upon hearing the call for blood, the patient's husband will inform the learners that she is a Jehovah's Witness and has religious objections to all human-derived blood products. Learners should consider alternative therapy options including vasopressors, desmopressin, tranexamic acid, recombinant factor VII, iron, erythropoietin, and early placement of a gastroesophageal balloon tamponade device. The simulation nurse will inform the learners of recurrent massive hematemesis and altered mental status, which should prompt the learners to prepare for intubation to protect the patient's airway. Their plan should account for the patient's mechanically difficult airway secondary to obstructed views from massive hematemesis, as well as her physiologically difficult airway secondary to hypotension. They should pre-oxygenate in the upright position, improve the blood pressure prior to intubation with vasopressors, utilize direct laryngoscopy, multiple large-bore suction catheters, and utilize the suction-assisted laryngoscopy and airway decontamination (SALAD) technique to visualize the vocal cords.

INSTRUCTOR MATERIALS
As a result of the patient's recurrent massive hematemesis prior to intubation, as well as the limitations on blood product resuscitation, learners should recognize the need for rapid control of bleeding and should consider gastric balloon tamponade using a Blakemore or Minnesota tube (whichever is available in your hospital). Failure to confirm gastric balloon placement with chest radiography prior to full insufflation of the gastric balloon, or insufflation of the esophageal balloon without pressure monitoring, will result in rapid decompensation from esophageal rupture. A correctly placed balloon tamponade device will result in improvement of vital signs and bleeding. Gastroenterology, interventional radiology, and the intensive care unit (ICU) should all be consulted. A head CT should be obtained prior to transport to the ICU to evaluate for subdural hemorrhage now that the patient is stabilized.
Critical actions: 1. Assess airway, breathing and circulation 2. Connect the patient to the cardiopulmonary monitor and obtain large bore IV access 3. Obtain a thorough history and perform a complete physical exam 4. Assess for causes of UGIB 5. Initiate pharmacologic therapy for UGIB from suspected varices including octreotide, ceftriaxone, proton pump inhibitor, and blood 6. Order a CT head due to head trauma in a patient with alcoholic cirrhosis 7. Monitor closely for worsening bleeding by frequent clinical assessments or placing a nasogastric tube 8. Assess for airway protection in patient with worsening clinical status and establish endotracheal intubation 9. Consider at least three alternatives to blood product administration for UGIB in patient who is a Jehovah's Witness 10. Place a gastroesophageal balloon tamponade device for massive UGIB to control the worsening bleeding • History of present illness: She had two episodes of two tablespoons of bright red hematemesis this morning and then became lightheaded and had a syncopal episode just prior to arrival, prompting her visit to the ED. She had one episode of melena yesterday. She denies chest pain, bleeding disorders, or being on blood thinners. If asked specifically, she drinks alcohol daily and has a history of "liver disease" but doesn't know anything more about it. • Past medical history: "Liver disease," "heart disease," and "kidney disease" • Past surgical history: None • Patient's medications: "two pee pills" (furosemide and spironolactone), and "a poop pill" (lactulose)

Massive Upper Gastrointestinal Bleeding in a Jehovah's Witness
The diagnosis of UGIB is typically fairly straightforward, and is suggested by hematemesis and melena, but should also be suspected in unstable patients with massive hematochezia. A higher index of suspicion for occult UGIB needs to be maintained as an underlying cause of generalized weakness, dizziness, and syncope. Etiologies of UGIB are extensive and include esophageal varices, peptic ulcers, esophagitis, gastritis, and vascular malformations.

General treatment of Upper GI Bleeding:
• Proton pump inhibitors are typically administered for all patients with UGIB. There is no mortality benefit, but they have been shown to reduce endoscopic stigmata of recent hemorrhage and need for endoscopic intervention. 8 This is generally given as pantoprazole 80mg IV bolus. A subsequent drip has not been shown to be beneficial. • Octreotide causes splanchnic vasoconstriction, which leads to a modest decrease in bleeding in the setting of variceal UGIB. 9 There is no known mortality benefit. Octreotide is generally given to all patients with cirrhosis and an UGIB as a bolus of 50 mcg IV followed by a drip at 50 mcg/hr. • Antibiotics are the only pharmacologic therapy that have been shown to have mortality benefit for UGIB in cirrhotic patients. 10 This is felt to be due to decreased bacterial gut translocation and prevention of spontaneous bacterial peritonitis. Typically, a thirdgeneration cephalosporin is administered. • Blood transfusion is reserved for acute blood loss anemia and hemodynamically significant active bleeding, regardless of the hemoglobin level. • Definitive treatment includes endoscopic banding, cautery, and injection, as well as endovascular embolization and the trans-jugular intrahepatic portosystemic shunt (TIPS) procedure.

Management of hemorrhage in patients who are Jehovah's Witnesses
The religious objection to human-derived blood product administration amongst Jehovah's Witnesses stems from a belief that it may affect their eternal salvation. As such, this objection is often fervent, and alternative therapies may be needed. 2,3 • Recombinant factors VII, VIII, IX are available and are made by cloning the human factor gene and growing it in culture media without human protein or serum, and are therefore acceptable for use by Jehovah's Witnesses. Evidence is scarce and these therapies are likely expensive and not always available. • Desmopressin (DDAVP) can be used to release endogenous von Willebrand factor and factor VIII, and can improve platelet dysfunction, which may be especially useful if bleeding is felt to be, at least partially, uremic or related to NSAIDS or other platelet inhibitors. • Vasopressors and IV fluids can be used to help support blood pressure, and may be necessary, but they will not increase oxygen carrying capacity, and IV fluids may actually be harmful due to dilution. • Tranexamic acid (TXA) is useful in the treatment of traumatic and post-partum hemorrhage; however recent high-quality evidence (HALT-IT trial) suggests no mortality benefit in the setting of GIB, and there is an increased risk of venous thromboembolism and seizures. 11 These complications were still quite rare (<1%), and shared decision making may be appropriate in this case, where other therapies are limited, but in general, TXA is not recommended for GIB treatment. • Iron infusion and erythropoietin will help the patient regenerate additional red blood cells if they survive the initial UGIB. These medications will not help acutely and likely do not need to be administered in the ED. • Early hemorrhage control is perhaps the most critical intervention in patients who object to blood transfusions. When both blood pressure and oxygen carrying capacity cannot be simultaneously supported with blood, early definitive therapy with endoscopic or endovascular interventions may be needed, even in a stable patient. In an unstable patient, early gastro-esophageal balloon tamponade may be life-saving.

Contaminated Airway Management
Intubating a contaminated airway with vomitus or blood can be extremely challenging. Preoxygenation can be nearly impossible, visualization of the vocal cords and other airway structures can be severely limited, and aspiration is extremely common. Video laryngoscopes tend to be obscured by airway contaminate, and even direct laryngoscopes can have their light source diminished by contact with opaque substances in the airway. Traditional suction devices, like the Yankhauer , are often inadequate due to their limited suction capacity and tendency to be easily clogged and rendered useless by chunky emesis or even blood clots. Techniques to decontaminate the airway, improve visualization, and increase the chances of first-pass intubation success include: • Direct laryngoscopy is generally recommended over video laryngoscopy, which is commonly obscured by airway contaminate. • The upright position should be used for pre-oxygenation and intubation where possible to decrease the risk of aspiration. • Multiple suction catheters as well as large-bore suction devices, where available, should be used to improve the rate of airway decontamination. One of these can be placed and left in the esophagus for continuous suction. • The suction-assisted laryngoscopy and airway decontamination (SALAD) technique is a method of laryngoscopy designed specifically for management of the vomit-filled airway. 7 It involves leading with a large-bore suction device, followed by a direct laryngoscope. The suction device is then positioned in the esophagus for continuous suction, while it is shifted to the left of the patient's mouth and held in place by the left border of the laryngoscope. This leaves the right side of the oropharynx open and cleared for tube delivery and additional suction as needed. A video demonstration of this technique is listed below. • Airway adjuncts are also useful to have available. These include a bougie, intubating LMA (laryngeal mask airway), and a cricothyroidotomy kit, should airway contaminate be so severe that a "can't intubate, can't ventilate" situation arises.

Gastroesophageal Balloon Tamponade Devices
Gastroesophageal balloon tamponade devices, including the Blakemore and Minnesota tubes, are designed to temporize variceal upper GI bleeding by applying direct pressure to bleeding gastric and esophageal varices. The Blakemore and Minnesota tubes each have a gastric and esophageal balloon that can be inflated separately to tamponade adjacent bleeding varices, as well as a gastric section port at the distal tip of the tube. The Minnesota tube is a modified version of the Blakemore tube that has an additional suction port on top of the esophageal balloon, obviating the need for placement of an OG tube alongside the Blakemore tube to assess for persistent esophageal bleeding after inflation of the gastric balloon. Another important difference between the two devices is that the Minnesota tube's gastric balloon accommodates significantly more air (500 cc versus 150 cc in the Blakemore tube).
The traditional indication for use of a gastroesophageal balloon tamponade device was to temporize a severe, life-threatening, suspected variceal bleed when definitive (endoscopic or endovascular) therapy is delayed. This is likely due to the high complication rate of balloon placement. However, when unable to stabilize a patient with blood transfusions (due to religious objection or resource availability), early control of bleeding is of critical importance and should prompt consideration of early balloon placement. Additionally, as has recently been pointed out in a March 2021 episode of EM:RAP, there are a number of steps that can be taken to significantly decrease the complication rate of balloon placement, making this procedure substantially safer than original reports. 12 As such, placement of these devices can likely be considered much earlier, when the patient is beginning to become unstable, well before they are peri-arrest. These steps include intubating the patient prior to device placement to prevent asphyxiation from accidental oropharyngeal balloon inflation, obtaining an x-ray prior to fully inflating the gastric balloon to ensure it is not in the esophagus, and only inflating the esophageal balloon when necessary and when a manometer can be used to prevent over-inflation and esophageal rupture.
The insertion of a Blakemore or Minnesota tube is best explained in video format. [4][5][6]13 Below are a number of videos that review how these devices should be used. However, the actual insertion of the device through the oropharynx and into the esophagus and stomach is much easier said than done. Some tricks to improve device placement include stiffening up the tube by soaking it in ice water (usually while performing endotracheal intubation) prior to use, or using the back end of a pediatric bougie placed into the most proximal of the gastric aspiration ports. 13

Wrap Up:
Here are some excellent videos summarizing the differences between the gastroesophageal balloon tamponade devices on the market and how to place the two devices you are most likely to have in your hospital. The last video demonstrates the bougie-assisted placement technique. We recommend watching the videos in this order: